Dear Editor,

We read with interest the article by Dang et al. [1] on “Behavioral Improvements following Lesion Resection for Pediatric Epilepsy: Pediatric Psychosurgery?”. We commend the authors for reporting their case series on the impact of epilepsy surgery on behavior, which is often a neglected topic and difficult to quantify. Improvement in behavior following epilepsy surgery is an important topic with mixed reported results in the literature [2‒6]. Variable reported results are compounded by small case series, different methodology and measures used in assessment of behavioral outcomes, and variable duration of follow-up [2‒6]. Previous systematic review studies have demonstrated that there is some evidence of improvement in emotional and behavioral functioning after epilepsy surgery [2]. However, this is confined to scores on parent-reported screening measures of emotional and behavioral symptoms and not clinical diagnoses [2]. We would like to highlight further that behavioral outcomes seen in children with lesional epilepsy can occur due to direct impact of location of lesion, effect of seizure on neural development, or impact on daily activity and functioning such as schooling and social interactions. Furthermore, the adaptive changes of the child in response to having seizures or epilepsy and the impact of anti-seizure medications on behavior, are further factors to consider. The multifaceted aspects and complex interactions of behavior, therefore, make assessment of final behavioral output a complex task to quantify and report, even using standardized currently available tools.

In addition to improvement in behavior seen in children following successful epilepsy surgery and seizure freedom, we also encounter deterioration in behavior in some cases which could be due to cessation of seizure activity, unmasking an underlying diagnosis, or loss of mood stabilizing effect of anti-seizure medications on the weaning phase.

We too agree with the authors that in some children such as case 5 reported in their study, severity of seizure frequency may not fully explain the disproportionate impact on behavior and therefore surgical resection of some accessible epileptogenic lesions could be considered in special circumstances following a case-by-case assessment through multidisciplinary discussion to minimize the impact of seizure on child’s behavior.

Authors report no conflict of interest.

No funding was received for this study.

Fardad T. Afshari and Muhammad Zubair Tahir have drafted this letter to the editor.

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